0303-148 (RPL)LICENSED CONTRACTOR DECLARATION
_Xhereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
656128
rte.
Date/` Signature of Contractor kA
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
perf0 ante of the work for which this permit is issued.
(C) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier �J'd'&TV, CialV11�ENS�' TI Policy No. 046-6169-2003
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit'is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of S ction 3700 of the Labor
Code, J,shallforthw.ith comply with Those p¢ovisions
Date: "�'a -Q1 Applicant�,S,i(�c.:ttr�,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and'Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
> whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit 'is -sued as a result of this application becomes null and void if
work is not commenced within 180 days from date .of issuance of such
permit, or cessation of work for 180 days will,subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with,.all City, and State laws relating to the building
ow
construction, and hereby authorize representatives ofb. this City to enter upon
the above-mentioned property for�inspection purpose
,F C i
Signature (Owner/Agent) Date r
u r
BUILDING PERMIT PERMIT-�<
DATE V -1 -VALUATION LOT.,. TRACT
JOB SITE
ADDRESS `� 1ai.�
APN
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
MWA LA Qi7i MTA
CAT JF01MAPOOLS & SPAS. Cf UP IttNN CC,
60-311 TRILOGT 'AP',Z .f+, a
86.1(9f1.'�.'VEI+7U :.5
LAQUIIrfA CA 92253
COAClUELLA CA 92236
C760)398.9222 MT 4f OG355
USE OF PERMIT
POOL MD/OR SPA
W-751VA4— d8 C P. Y kit;otc i.l r..Q
STANDARD. ALA0011113Al RU ttV Mki.I.. Ste~ lis KACT AT PRE-i'i' ASTER
YNSPECTION.
^i FT. WALL 20.00 U?
PO01,AIN WO SPA 1?IiS70 L.•S
Emy lA!I.A ry-0 Cofer oir CC1JdllwlIMC -0-K
1"10D1D 90
F=MfE Hi4I1RY
PLAN CHECK M 101-000-4,31,11-318. $aMh
Mjl TPIUCTION F!y(r 101.�C1A!J 1 i iS�(Iti{1 �1�9.(I!i
WIX,*HANICAL ME— P001, 1014000 21 0110 124,00 ;
it.�1,.EC.TRI CAL FM-- T*L"IOL 101-.000-420-000 $0.130
PLtSlkiBINI S 1?1£la, -. POOL . ' 161.0300,419»000 SR%06
•'. SM-TOTAL/rMCK
g"AOTHtC VRMCTION AM PLAN
4 M.115 1''F1J' PAit,1
$0,00
r PERM I'M,1510 DUE �' now
$407'.£5
r
CITY 6?r L<l CIUl�1 ai� � .:
C'INAiv°CE CiePV. •
RECEIPTDAfTE
't '
BY ?
DATE FINALED
INSPECTOR'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test I IV
Electric Final
Waste Livres
Heater Final
Water Piping
Plumbing Final
Rwmbing Top Out
Equipment Enclosure
Steer Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Encapsulation
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL 'APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: